S92.315A Nondisplaced fracture of first metatarsal bone, left foot, initial encounter for closed fracture

Name of the Condition

• Nondisplaced fracture of first metatarsal bone, left foot, initial encounter for closed fracture
• ICD-10 Code: S92.315A

Summary

A nondisplaced fracture of the first metatarsal bone in the left foot is a break where the bone fragments remain in their normal alignment. The first metatarsal is the long bone connecting the big toe to the midfoot and is a primary weight-bearing structure. This injury is localized to the left foot and is classified as closed (no break in the skin) during the initial encounter. Nondisplaced fractures typically result from trauma and may cause pain, swelling, and difficulty bearing weight, though the bone alignment remains intact.

Causes

Direct trauma to the left foot is the primary cause. Common scenarios include dropping a heavy object, a sports injury (e.g., twisting the foot during activity), or a fall. High-force impacts can cause the bone to fracture without displacing the fragments. Repetitive stress from activities like running or jumping may also lead to stress fractures over time.

Risk Factors

• Participation in high-impact sports (e.g., basketball, soccer)
• Wearing improper or non-supportive footwear
• Conditions that weaken bones, such as osteoporosis
• Advanced age, which may reduce bone density and balance
• Previous foot injuries or fractures

Symptoms

• Pain and tenderness at the base of the big toe (left foot)
• Swelling and bruising around the affected area
• Difficulty bearing weight or walking on the injured foot
• Possible mild deformity, though less likely than with displaced fractures

Diagnosis

A healthcare provider will perform a physical examination to assess pain, swelling, and range of motion. Imaging studies, such as X-rays, are typically used to confirm the fracture and verify that it is nondisplaced. The provider will also evaluate for signs of open fracture or other associated injuries.

Treatment Options

Treatment may include immobilization with a cast or walking boot to protect the bone during healing. Pain management with over-the-counter or prescription medications may be recommended. Weight-bearing restrictions are often advised initially, with gradual return to normal activity as healing progresses. Physical therapy may be prescribed to restore strength and mobility.

Prognosis and Follow-Up

Most nondisplaced fractures of the first metatarsal heal well with proper immobilization and rest. Healing typically occurs within 6–8 weeks, though this may vary. Follow-up appointments are important to monitor healing and adjust treatment as needed. Full recovery of function is common, but some individuals may experience residual stiffness or mild discomfort.

Complications

While rare, complications can include delayed healing, nonunion (failure to heal), or malunion (healing in an abnormal position). Infection is not a concern with closed fractures but may occur if the fracture becomes open. Chronic pain or arthritis in the big toe joint is possible in severe cases.

Lifestyle & Prevention

Wearing supportive footwear and avoiding high-impact activities that stress the foot can help prevent fractures. Maintaining bone health through adequate calcium and vitamin D intake may reduce risk. Proper warm-up and technique during sports or exercise can minimize trauma to the foot.

When to Seek Professional Help

Seek medical attention if pain is severe, swelling worsens, or weight-bearing becomes impossible. Signs of infection (e.g., redness, pus, fever) or open fracture (bone visible through the skin) require immediate care. Persistent pain or difficulty walking after initial treatment should also prompt a follow-up with a healthcare provider.

Tips for Medical Coders

This code (S92.315A) specifies a nondisplaced fracture of the first metatarsal bone in the left foot, with an initial encounter for a closed fracture. Documentation should clearly indicate the fracture type (nondisplaced), location (left foot), and encounter stage (initial). Ensure the record supports the closed nature of the fracture and that no displacement is noted. Use this code only for the initial visit; subsequent encounters for the same injury would use different codes.